Clinical Judgment
This function of Clinical Judgment involves the assessment of vital signs, symptoms, health history, and environment.
What is Recognizing cues/assessment
What is a key responsibility when delegating tasks?
Ensuring the delegatee is trained for the task.
What is a fundamental component of Clinical Judgment that involves analyzing information, questioning assumptions, and making informed decisions?
What is Critical Thinking
When a nurse is contemplating whether delegation is appropriate. Which would help the nurse make this decision?
1. Patient's Bill of Rights - 2. Nurse Practice Act - 3. Facility policy and procedure manual - 4. The Joint Commission Guidelines
The nurse is caring for a patient exposed to cold whose toes are pale and blanched. Which action should the nurse take?
1. Vigorously rub the affected area to promote circulation. - 2. Don't worry about it unless the fingers are turning dark/black. - 3. Place the hands in warm water for 15-30 minutes. - 4. Place hands under hot running water for 15-30 minutes.
3. Place hands in warm water for 15-30 minutes
In this phase of Clinical Judgment, recognized cues are linked to the client's clinical presentation, establishing probable client needs.
What is Analyze cues
Name one of the "Five Rights" of delegation.
Right task, Right Circumstance, Right Person, Right Directions, or Right Supervision.
In Clinical Judgment, what is the process where nurses evaluate available options, weigh potential outcomes, and choose the most suitable course of action?
What is Decision Making
1. Stop the infusion - 2. Notify the physician - 3. Elevate the extremity - 4. When the infusion is complete, remove the tubing and send it to the laboratory for analysis.
1. The findings are consistent with infiltration and the VI fluid should be stopped immediatley
Which patient are you most concerned about their hypovolemia status?
1. Patient that was admitted with sepsis and has had a temp for several days, BP of 88/45, HR 118, RR 24
2. The patient that fell from the tree & has bil. femur fractures, liver & spleen injury. BP 88/45,HR 118, RR 24
3. A post op patient from 2 hours ago that has had several does of dilaudid and antiemetics. BP 88/45, HR 114, RR 24
4. Patient with nausea and vomiting x 8 hours, has had antiemetic but no fluids.
2. The patient that fell from the Tree with bil femur Fx and liver and spleen injury.
This function involves establishing priorities of care based on the client's health problems.
What is Prioritizing hypotheses
Define delegation in nursing.
Assigning tasks while retaining accountability for outcomes.
How do nurses utilize critical thinking in Clinical Judgment to navigate the complexities of patient care?
What is by Assessing and Interpreting Data
A patient is receiving all fluids, food and medications via a percutaneous endoscopic gastrostomy (PEG) tube. The pharmacy sends a sustained-released opioid medication for pain control. What action should the nurse take?
1. Provide the medication orally - 2. Crush the medication and put it through the tube - 3. Dissolve the medication in water and administer it through the tube - 4. Ask the physician to prescribe the medication as an elixir for tube administration
4. The nurse should ask the physician to prescribe the medication as an elixir for tube administration because a time-released tablet should never be crushed.
The nurse is having difficulty assessing the pain of an alert 42 y.o. nonverbal patient. Which method should the nurse use first to determine the patient's pain level?
1. Use the FACES scale - 2. Use a behavioral pain scale - 3. Don't worry about it since they cannot answer - 4. Explain the 0-10 scale
1. Use the FACES scale.
The nurse is using the Clinical Judgment process to provide care to a patient experiencing nausea. During the process of generating solutions, the patient begins to vomit. What should the nurse do next? 1. Take actions as prepared. 2. Evaluate outcomes of the solutions generated. 3. Identify and analyze the new cues presented. 4. Generate different solutions.
3. At any point in the cycle of Clinical Judgment, if a problem is encountered or something changes, the nurse should go back a step or two in the process and try again.
Give one legal or ethical consideration in delegation.
Patient Safety and Accountability
Name a component of Clinical Judgment across the lifespan.
What is Recognize and Analyze Cues
Or
Evaluate Outcomes
You are taking the history of a patient who is scheduled for surgery in which he was to remain NPO after midnight. You ask the patient when he last had something to eat, to which he replies, "About 2 hours ago." Which action should the nurse take?
1. Document the response and send the patient to surgery. - 2. Notify the surgeon immediately. - 3. Tell the patient to come back that afternoon. - 4. Ask the patient what he ate: liquids are okay.
2. The patient was NPO after midnight but ate 2 hours before surgery. The surgeon should be notified, as the surgery may be rescheduled.
The nurse is caring for a 3 year old with croup. The nurse is getting ready to give the steroid. Which route has the best efficacy?
1. Oral
2. Rectal
3. Intramuscular (IM)
4. Intravenous (IV)
1, oral
3, IM
4, IV
What is the final step in Clinical Judgment?
What is evaluating outcomes
How do Clinical Judgment and Delegation connect?
Both support patient outcomes through decision-making and appropriate task assignment.
It strengthens decisions with proven research
Your patient states her last menses was on March 7, 2008. Using Nagele's rule, the nurse estimates the due date to be this?
What is December 14, 2008
1. recognizes clues or cues
2. Analyzes & makes an interpretation of the cues
3. Prioritizes hypotheses
4. Generates a solution with subsequent implementation of appropriate nursing actions
5. Evaluates the outcomes of the action